What is the recommended follow-up regimen for patients after radical nephroureterectomy (removal of the kidney and ureter)?

Follow-up Regimen After Radical Nephroureterectomy

The recommended follow-up regimen after radical nephroureterectomy should include history and physical examination every 3-6 months for 3 years, then annually up to 5 years, with baseline abdominal imaging within 3-6 months and continued imaging every 3-6 months for at least 3 years, then annually up to 5 years. 1

Risk Stratification for Follow-up

Follow-up intensity should be tailored based on pathological staging:

Low-Risk Patients (pT1, N0, Nx)

• Clinical evaluation: H&P every 6 months for 2 years, then annually up to 5 years 1
• Laboratory testing: Comprehensive metabolic panel every 6 months for 2 years, then annually up to 5 years 1
• Abdominal imaging:
  • Baseline abdominal CT or MRI within 3-12 months after surgery 1
  • If initial postoperative imaging is negative, additional abdominal imaging may be performed at physician discretion 1
• Chest imaging: Yearly chest X-ray or CT for 3 years, then as clinically indicated 1

Moderate to High-Risk Patients (pT2-4N0 Nx or any stage N1)

• Clinical evaluation: H&P every 3-6 months for 3 years, then annually up to 5 years 1
• Laboratory testing: Comprehensive metabolic panel every 6 months for 2 years, then annually up to 5 years 1
• Abdominal imaging:
  • Baseline abdominal CT or MRI within 3-6 months after surgery 1
  • Continued imaging (CT, MRI, or US) every 3-6 months for at least 3 years, then annually up to 5 years 1
  • CT is preferred over ultrasound for high-risk patients 1
• Chest imaging:
  • Baseline chest CT within 3-6 months 1
  • Continued imaging (CT or chest X-ray) every 3-6 months for at least 3 years, then annually up to 5 years 1

Special Considerations

Imaging Modality Selection

• CT is the preferred modality for patients with higher risk of recurrence 1
• Ultrasound is an acceptable alternative for low-risk patients, though there is disagreement among experts regarding its usefulness in stage III disease 1
• For patients with impaired renal function, consider non-contrast CT or MRI without contrast 2

Site-Specific Imaging

• Imaging of the pelvis, CT/MRI of the head, MRI of the spine, or bone scan should be performed as clinically indicated 1
• Patients with neurological signs or symptoms should undergo prompt neurological cross-sectional imaging (CT or MRI) of the head or spine 1
• Bone scan should only be performed with elevated alkaline phosphatase or clinical symptoms like bone pain 1

Monitoring for Recurrence

• Local recurrence rates for smaller tumors after nephrectomy are 1.4% to 2.0% versus 10.0% for larger tumors 1
• Moderate to high-risk tumors have a substantially higher risk of both local and metastatic recurrence (approximately 30% to 70%) 1
• Patients with a history of bladder carcinoma in situ, multifocal tumors, or tumors in the renal pelvis have higher recurrence rates 3

Renal Function Monitoring

• Renal function typically declines by approximately one-third after radical nephroureterectomy and does not show evidence of recovery over time 4
• Elderly patients and those with preoperative eGFR closer to 60 mL/min/1.73 m² are more likely to be ineligible for adjuvant cisplatin-based chemotherapy due to renal function loss 4

Duration of Follow-up

• The most intensive follow-up should occur during the first 3-5 years after nephroureterectomy 1
• Imaging beyond 5 years may be performed at the discretion of the clinician based on individual patient characteristics and tumor risk factors 1
• For relapsed or stage IV disease, more frequent follow-up is required with imaging every 6-16 weeks adjusted according to the rate of disease change and sites of active disease 1